Individual
SHELLEY MARIE JACKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1055 N CURTIS RD, BOISE, ID 83706-1352
(208) 367-6416
Mailing address
PO BOX 4268, PORTLAND, OR 97208-4268
(503) 372-2740
(503) 372-2754
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
M7159
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
050075060
RAILROAD MEDICARE
ID
05
—
805793000
—
ID
Enumeration date
05/12/2006
Last updated
04/08/2011
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